Nurse Practitioner Behavioral Health Questionnaire

Date form was completed

Name

Date of Birth

Age

Briefly describe the reason for coming in. Approximately how long has this been a problem.

Medical and Physical History

Name, Address and Phone Number of Primary Care Physician

Date of last physical exam

It may be beneficial for your therapist to communicate with your PCP. Please check here if you give your consent for us to communicate with your PCP.

I give consent for the Nurse Pracitioner to speak with my PCP

Yes No

Any specialist you are working with and would like the NP to communicate with, please list the names and phone numbers.

Please list all medical hospitalizations, dates, and reasons for hospitalziations

Please list all out-the counter and prescription medications you are currently taking.

Are you allergic to any medications?

Yes No

List all drugs, medications and substances you are allergic to and the reaction.

PREVIOUS BEHAVIORAL HEALTH TREATMENT

Please list all of the behavioral health and chemical dependency treatment you have had, including dates, therapists or hospital, problem(s), diagnoses

Please list any other psychiatric medications you have tried in the past. Please list the names of the medication, dose of medication, dates of use and reason for stopping.

Current therapist and length of current therapy

Address & Phone Number of Current Therapist

Have you attempted suicide?

Yes No

Physical Symptoms

Physical Symptoms: In the last 4 weeks, have often have you been bothered by the following

For the following questions, please indicate a:

0 Not bothered at all
1 Bothered a little
2 Bothered a lot

Stomach Pain

0 1 2

Back Pain

0 1 2

Chest pains

0 1 2

Headaches

0 1 2

Diarrhea

0 1 2

Neck Pain

0 1 2

Shortness of breath

0 1 2

Constipation

0 1 2

Sexual Dysfunction

0 1 2

For women: Menstrual cramps or problems with period

0 1 2

Current Depressive Symptoms: Over the last 2 weeks, how often have you been bothered by any of the following problems? For the following questions, please indicate if you have experienced these problems--

0 Not at All
1 Several Days
2 More than Half the Days
3 Nearly Every Day

Depressed or sad mood

0 1 2 3

Little interest or pleasure in doing things.

0 1 2 3

Poor appetite or overeating

0 1 2 3

Low self esteem

0 1 2 3

Trouble concentrating on things, such as reading the newspaper or watching television.

0 1 2 3

Feeling bad about yourself or that you're a failure or have let yourself or your family down.

0 1 2 3

Feeling hopeless/helpless

0 1 2 3

Anger/Irritability

0 1 2 3

Fatigue/loss of motivation

0 1 2 3

Crying

0 1 2 3

Social Isolation

0 1 2 3

Negative thoughts

0 1 2 3

Thoughts that you would be better off dead or of hurting yourself in some way.

0 1 2 3

Self-injurious Behavior

0 1 2 3

Trouble falling/staying asleep, or sleeping too much.

0 1 2 3

# of Hours of Sleep per Day

Homicidal Thoughts

0 1 2 3

Other Mood Symptoms: Have you been bothered by any of the following problems for at least one week? For the following issues, please use the following scale.

0 Not at all
1 Several Days
2 More than Half the Days
3 Nearly Every Day

Extreme happiness, hopefulness and exhilaration

0 1 2 3

Restlessness, increased energy, and need for little or no sleep

0 1 2 3

Talking rapidly or excessively

0 1 2 3

Poor decision making

0 1 2 3

Higher than your normal sex drive

0 1 2 3

Racing Thoughts

0 1 2 3

Showing poor or impulsive judgment

0 1 2 3

Inflated self-esteem or grandiosity--greatly heightened beleifs about your ability, intelligence and powers

0 1 2 3

Increased reckless or self injuring behaviors (such as spending sprees, driving recklessly, impulsive sexual indiscretions, abuse of alcohol or drugs, or ill-advised business decision.

0 1 2 3

Anxiety

In the last 4 weeks, have you had an anxiety attack - suddenly feeling fear or panic

Yes No

If you have had an anxiety attack or panic attack in the last 2 weeks,

Has this ever happened before?

Yes No

Do some of these attacks come suddenly out of the blue –– that is, in situations where you don’t expect to be nervous or uncomfortable

Yes No

Do these attacks bother you a lot or are you worried about having another attack?

Yes No

How's your Eating?

Do you often feel that you can’t control what or how much you eat?

Yes No

Do you often eat, within any 2-hour period, what most people would regard as an unusually large amount of food?

Yes No

Are you preoccupied with your body image?

Yes No

In the last 3 months have you often done any of the following in order to avoid gaining weight?

Made yourself vomit?

Yes No

Use of diet pills

Yes No

Intentionally trying to lose weight by restricting food intake or fasting

Yes No

Exercised for more than an hour specifically to avoid gaining weight after binge eating?

Yes No

Took more than twice the recommended dose of laxatives?

Yes No

Substance Abuse History

Do you drink coffee/caffeine/energy drinks, yes or no? If yes, How many cups per day?

Do you use tobacco or e-cigarettes. yes or no? If yes, please quatify?

Do you ever drink alcohol (including beer or wine)?

Yes No

Have any of the following happened to you more than once in the last 6 months?

You drank alcohol even though a doctor suggested that you stop drinking because of a problem with your health.

Yes No

You drank alcohol, were high from alcohol, or hung over while you were working, going to school, or taking care of children or other responsibilities.

Yes No

You missed or were late for work, school, or other activities because you were drinking or hung over

Yes No

You had a problem getting along with other people while you were drinking.

Yes No

You drove a car after having several drinks or after drinking too much

Yes No

For Men, in the past year, how often have you had 5 or more drinks in a day?

For Women, in the past year, how often have you had 4 or more drinks in one day?

In the past year, how often have you used prescription drugs for non-medical reasons?

In the past year, how often have you used illegal drugs?

Are you in or have you had any of the following treatment for substance use?

Rehab

Detox

Outpatient

AA/NA

Attentional/Behavioral Symptoms

Abuse/Trauma

Is there a history of abuse or intimate partner violence?

Yes No

Family History

Please list family members who have been diagnosed with psychiatric illness. Please identify the relationship to you and their diagnosis or symptoms.

Did anyone in your family ever die of sudden cardiac event under the age of 35?

Yes No

Social History

Do you exercise regularly?

Yes No

Do you eat a well-balanced diet?

Yes No

Are you currently employed?

Yes No

Occupation and Employer

Military Service: Have you ever served in the military?

Yes No

If yes, did you have combat exposure?

Yes No

Are you a student? If yes, what school and grade level?

If no, did you graduate from high school or earn a GED?

Education: Please indicate if any of the following apply to you?

Do you have any learning disabilities?

Did you repeat any grades?

Do (Did) you have any discipline problems?

Do (Did) you have a 504 plan or IEP?

Disability: Are you currently on disability? If yes, why?

Activities: Are you involved in any faith based, sports or club activities?

Are you currently involved in court proceedings or litigations such as child custody, worker’s compensation, auto accident or criminal proceedings? Please explain.

Do you have access to firearms?

Yes No

If yes, are they secured?

Yes No

Developmental Milestones (for Kids 15 & Under

Developmental delays: Any delay with walking, potty training?

Yes No

Any complications with pregnancy or delivery?

Other

Please add any additional information that you believe may be helpful.

I give permission to have appointment reminder texts sent to me

If yes, indicate the cell phone number you prefer for your reminders

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